Birth & Beyond Childbirth Education Series, by Alex Sullivan (Led By Love)
Birthing Person’s First and Last Name *
Your answer
Birthing Person’s Cell Phone Number *
Your answer
Birthing Person’s Email Address *
Your answer
Home Address *
Your answer
When is your estimated guess date? *
MM
/
DD
/
YYYY
Partner's First and Last Name *
Who will be present at the birth and attending these classes with you? If not applicable, please respond N/A below?
Your answer
Partner's Cell Phone Number
Your answer
Partner's Email Address
Your answer
Is it ok to contact your partner?
Who is your care provider for this pregnancy? *
Your answer
Where is your planned place of birth? *
(Please indicate which hospital or home birth location)
Your answer
How did you hear about this series? *
Your answer
What number pregnancy is this? *
Your answer
What number birth is this? *
Your answer
If you have had other births, please list if they were vaginal or cesarean and tell me anything else you'd like to share about your previous birth experiences:
Your answer
Do you plan to have any other labor support present at birth? *
Required
If yes, who will be attending the birth other than your partner?
Your answer
How do you feel about taking this course? *
Your answer
How does your partner feel about taking this course? *
Your answer
What is one thing you hope to learn from this course? *
Your answer
What is the most important goal you have for your birth?
Your answer
List any special concerns or information you would like me to know prior to starting class:
Your answer
Which series are you signing up for? *
Do you have any questions or for me?
Your answer
A $50 deposit is needed to hold your spot. Upon submission, you may send partial or full payment to PayPal or Venmo - ledbylovedoula@gmail.com
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